P - 35068Building
Inspections
763-572-3604
763-502-4977 FAX
DATE f 1 ^ �
SITE ADDRESS _�
THIS APPLICANT IS:
PROPERTY
OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
MECHANICAL
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
E-MAIL ADDRESS
❑ OWNER �ONTRACTOR
ADDRESS:
COMPANY
CITY
��
Permit No.: � �o�a ��3
Received By:
Da ' c� �'U JI. � �
ATE
CONTACT PERSON: FLOYD JOSWICR
STATE LICENSE # EXP DATE
ADDRESS: %22� UIIlVerSl�y AVe. N. E. CITY Frldl@y STATEMN ZIP 55432
PHONE 763-572-0459 Fa�x 763-572-01 64
TYPE OF WORK: � o rrEw
FAMILY � ❑ TWO FAMILY
DETAILED DESCRIPTION OF WORK
� TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WEIERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW).
PROVIDE HEAT LOSS CALC'S PER MANUA J 2�RAE HANDBOOI{.
Equipment Installed MFG: MODEL: � SIZEBTU
MFG: MODEL: SIZEBTU
MFG: MODEL: SIZEBTU
A/C $25.00 FIREPLACE (GAS) $15.00 _GAS RANGE/OVEN $10.00
AIR TO AIR EXCHANGEER $15 FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
_BOILER $35.00 T�FURNACE $35.00 GAS UNIT HTR $]0.00
_CHIMNEY LINER $10.00 _GAS DRYER $10.00 POOL HEATER $35.00
_DUCT WORK $l0.00 GAS PIPMG $10.00 VENTILATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an app 'cation for a permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of 11 work re ' es review and approval of plans.
SIGNATURE OF APPLICANT PRINT NAME V If ML�S � Q� DATE �� ��
APPROVALINSPECTORS
DA
City of Fridley
° Building Inspections Department
6431 UniversiTy Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977